Jan. 13, 2000 ST. PAUL, MN - Many brain-dead patients have spontaneous movements such as jerking of fingers or bending of toes that can be disturbing to family members and health care professionals and even cause them to question the brain-death diagnosis. These movements occur in 39 percent of brain-dead patients, according to a study published in the January 11 issue of Neurology, the scientific journal of the American Academy of Neurology.
“We found that these movements are more common than has been reported or believed,” said neurologist and study author José Bueri, MD, of J. M. Ramos Mejia Hospital in Buenos Aires, Argentina. “People need to know that these movements are spinal reflexes that do not involve any brain activity.”
The study examined all patients at the hospital during an 18-month period with a diagnosis of brain death. Of the 38 patients, 15 had these motor movements. In all cases, the movements were seen in the first 24 hours after brain death diagnosis, and no movements were seen after 72 hours.
Some of the movements occurred spontaneously; others were triggered by touch. Examiners used tests designed to elicit motor movements, such as lifting the arms or legs or touching the palm of the hand.
Electroencephalogram (EEG) tests did not show any brain activity in any of the patients with movements.
“If the lack of understanding of these movements leads to a delay in the brain death diagnosis or questions about the diagnosis afterwards, there can be important practical and legal implications, especially for organ procurement for transplantation,” Bueri said. “Family members and others need to understand that these movements originate in the spinal cord, not in the brain, and their presence does not mean that there is brain activity.
One of the most startling movements for family members and health care professionals is called the ‘Lazarus sign.’ It is a sequence of movements lasting for a few seconds that can occur in some brain dead patients, either spontaneously or right after the ventilator is disconnected,” Bueri said. It is named for the episode in the Bible where Lazarus is raised from the dead.
“It starts with stretching of the arms, followed by crossing or touching of the arms on the chest, and finally falling of the arms alongside the torso,” he said. “It is also a spinal reflex, but it can be disturbing to family members and others who see this.”
Another article in this issue of Neurology describes unusual movements in two brain dead patients. The movements occurred in a 30-year-old woman and an 11-month-old baby at a hospital in Barcelona, Spain. Both patients extended their arms, flexed their wrists and curled up their fingers each time the mechanical ventilator inflated their lungs. The movements stopped after the patients were disconnected from the ventilator.
“We had never seen these type of movements before, and they hadn‘t been reported in the medical journals,” said neurologist Joan Martí-Fàbregas, MD, PhD, of the Hospital de la Santa Creu i Sant Pau.
The doctors conducted additional tests and confirmed that there was no brain activity. “The living cells that were ordering these muscles to move were not brain cells or brain stem cells, but cells located in the spinal cord,” he said. “It‘s important for family members and health care professionals to be aware of this possibility.”
A neurologist is a medical doctor with specialized training in diagnosing, treating and managing disorders of the brain and nervous system.
The American Academy of Neurology, an association of more than 16,000 neurologists and neuroscience professionals, is dedicated to improving patient care through education and research. For more information about the American Academy of Neurology, visit its Web site at http://www.aan.com. For online neurological health and wellness information, visit NeuroVista at http://www.aan.com/neurovista.
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